Referral Guidelines for Imaging of Children and Young Adults

Caries diagnosis: initial visit

Initial clinical examination – intraoral posterior bitewing radiographs


Posterior bitewing radiographs are an essential adjunct to clinical examination.

The initial clinical examination must include an assessment of caries risk (as high, medium or low). The assessment of risk is relevant in determining when to take radiographs and therefore must be carried out at each subsequent recall examination ensuring that the time interval for radiography becomes patient-specific. It is feasible that adoption of the following recommendation may lead to more radiographs being taken (IAEA).

Intraoral bitewing radiographs


For high and moderate caries risk patients, there is a significant addition to diagnostic yield of clinical examination alone. For low caries risk patients, there is less strong evidence.

Where a child is classified as high caries risk the subsequent bitewing examination should be after 6 months intervals between subsequent bitewing radiographic examinations must be reassessed for each new period, as individuals can move in and out of caries risk categories with time (IAEA).

Fibreoptic transillumination (FOT)NoneIndicatedUseful adjunct to radiography for detection of aproximal lesions (IAEA).

Laser fluorescence methods

Infrared Laser Fluorescence (DIAGNOdent)

NoneSpecialised investigation

Adjunct to radiography, but with significant false positive rates (IAEA).

Electrical Conductance Measurement (ECM)
Quantitative Light-induced Fluorescence (QLF)
Digital Imaging Fiber Optic Transillumination (DIFOTI)Alternative methods to using ionising radiation in caries diagnosis should be considered once their diagnostic validity has been clearly established (IAEA).
Caries diagnosis: monitoringClinical examinationNoneIndicatedClinical examination of dried tooth surfaces with good lighting is essential at all stages of monitoring and review in caries detection (IAEA).
Intraoral bitewing radiographsIndicated

Intervals between radiographic examinations dependent upon clinically assessed caries risk status.

Ø  Moderate caries risk children:

the subsequent bitewing examination should be after

12 months. Evidence of no new or active lesions would be an indicator that the child had entered the low risk category.

Ø  Low caries risk children:

the subsequent bitewing examination should be after 12-18 months in the deciduous dentition and 24 months in the permanent dentition. More extended recall intervals may be employed if there is explicit evidence of continuing low caries risk (IAEA).

Table 1.1: Caries Risk Factors RP136

Endodontic treatment IAEA i RP172

Endodontic therapy: working length estimationIntraoral periapical radiographIndicated

More than one radiograph may be needed in multi-rooted teeth to avoid superimpositions and allow parallax localisation of roots and canals.


Electronic apex locatorNoneIndicated

Normally need confirmation of measurement by radiography, although some guidelines suggest that apex locators may be used alone in selected cases when the operator has confidence in the reading.


Indicated only in specific circumstancesIf high resolution CBCT is already available, then this may allow measurement of working length, but CBCT should not be used as the normal method of working length estimation.

Endodontic therapy:

Mid-fill (“Master point”)

Intraoral periapical radiographIndicatedRadiograph of tooth with master gutta percha cone in position may be indicated, depending on clinical judgement.

Endodontic therapy:

end of treatment

Intraoral periapical radiographIndicated

End of treatment radiograph needed for confirmation of adequate obturation and as a baseline for future image comparison.


Endodontic therapy:


Intraoral periapical radiographIndicatedRecommendations on timing of review radiography is inconsistent between guidelines and lacks an evidence base. A review at 12 months after treatment completion has some evidence to support it. Review after this point depends on clinical judgement.


Trauma (teeth and alveolar bone) (IAEA i RP172)Intraoral periapical radiographIndicatedCombinations of intraoral radiographs using different perspectives provide fine detail and are usually sufficient for dental trauma.
Intraoral occlusal radiographIndicated
Panoramic radiographIndicatedProvide more extensive coverage of bone for suspected dento-alveolar fracture.
CBCT  to
Indicated only in specific circumstancesLocalised high resolution CBCT appears to have higher diagnostic accuracy for root fracture detection, but is indicated only when conventional radiographs have proved to be inadequate for patient management. High level of patient cooperation is needed, as movement artefact will reduce fracture detection.
Trauma (maxillofacial)Panoramic radiographIndicated

Combinations of panoramic and facial bone radiographs are the traditional methods of detecting bone injuries.

CBCT and MDCT are increasingly replacing these.

Facial/skull radiographsIndicated
CBCT  to

Internal derangement of the temporomandibular joint (IAEA)

Internal derangement of the temporomandibular jointClinical examinationNoneIndicatedUsually provides the information required for diagnosis


Indicated only in specific circumstancesIn cases where there is uncertainty about the origin of the symptoms, e.g. potentially juvenile rheumatoid arthritis
MRNoneIndicated only in specific circumstancesIn cases where there is uncertainty about the origin of the symptoms, e.g. potentially juvenile rheumatoid arthritis